URETHROSTOMIES

Karen Tobias, DVM, MS, DACVS

University of Tennessee, Knoxville TN

Canine Scrotal Urethrostomy

Scrotal urethrostomy is most commonly performed in dogs with recurrent cystic and urethral
calculi. Other indications include penile neoplasia, trauma, or urethral stricture. In dogs, the
scrotal urethra is wide, distensible, and superficial, which makes it the preferred site for
permanent urethrostomy. Compared with prescrotal or perineal urethrostomy, scrotal
urethrostomy also reduces the risk of urine scald.

Preoperative Management
Before surgery, dogs should be evaluated for cystic and urethral calculi, cystitis, and metabolic
abnormalities such as uremia and hyperkalemia. Intravenous fluids are administered to correct
hydration, electrolyte, and acid base imbalances. If the dog is obstructed, urethral
catheterization should be attempted and any urethral calculi retropulsed into the bladder. Calculi
can then be removed by cystotomy. If the obstruction cannot be relieved, intermittent
cystocentesis or catheterization may be required until the animal is stable.

Ultrasound or abdominal and perineal radiographs are recommended to determine the number
and location of stones. Contrast cystourethrogram may be required for dogs with radiolucent
(e.g. urate) calculi.

In preparation for surgery, the scrotum and caudal abdomen are shaved and prepped. The
prepuce is flushed with antiseptic solution before scrubbing the area. For dogs undergoing
concurrent cystotomy, the entire abdomen is included in the prep. Epidurals provide excellent
intraoperative and postoperative analgesia. Dogs should be monitored after surgery to make
sure they urinate after epidural regional block.

Surgery

In unobstructed dogs, the urethra is catheterized during surgery to facilitate urethral

identification and dissection. Intact dogs are castrated after the scrotum has been incised.
Urethrostomy is performed over the caudoventral curve of the penile body where the urethra is
most superficial. Corpus spongiosum surrounds the urethra at this site, and bleeding is
expected until the urethrocutaneous anastomosis is complete. Apposition of urethral mucosa
and skin is usually performed with a simple continuous pattern using 4-0 rapidly absorbable
monofilament suture. Postoperative hemorrhage can be prolonged and significant when an
interrupted pattern is used. Some clinicians include bites of tunica albuguinea in the
urethrocutaneous closure.

In dogs with cystic calculi and urethral obstruction, scrotal urethrostomy is performed
simultaneously with cystotomy. This allows retrograde and antegrade catheterization and
flushing of the urethra before cystotomy closure. Calculi that are lodged within the urethra distal
to the urethrostomy site do not need to be removed.

Surgical Technique: Scrotal Urethrostomy

1. Make an incision through the scrotal skin.
a. If the scrotum is not evident, make the incision over the caudoventral curve of
penile body.
b. If the scrotum is pendulous, make an elliptical incision around redundant tissue.
Leave enough skin so that there will be no tension on the urethrostomy closure.
c. If the dog is intact, perform a scrotal ablation and closed castration to expose the
urethra.
2. With Metzenbaum scissors, dissect away the subcutis to expose the retractor penis
muscle ventral to the penile body. Resect the retractor penis muscle or elevate it and
retract it laterally.
3. Identify the urethra, which looks like a prominent vein on the ventral midline of the penile
body.
4. Make a small midline incision in the urethra over the caudoventral curve of the penile
body with a #11 or #15 blade. Use digital pressure to slow hemorrhage.
5. With tenotomy scissors or a blade, extend the midline urethral incision to 2 to 3 cm in
length.
6. Identify the cut edge of mucosa, which usually retracts away from the edge of the penile
body.
7. Suture the skin and mucosa together with a simple continuous pattern, using 4-0 rapidly
absorbable monofilament suture on a taper or tapercut needle.
 a. At one end of the incision, take a bite of urethral mucosa (less than ¼ the
diameter of the urethra, if possible) and skin, and tie two knots.
b. Take bites 2 to 3 mm apart and usually include 2 mm of the mucosa and 2 mm of
the skin.
c. Make sure to include mucosa in each bite, and avoid handling mucosa with
thumb forceps.
d. Complete the closure on the first side; then tie off and cut the suture. Repeat the
process on the opposite side.
8. Insert a hemostat or catheter into the urethral opening and place a mattress suture to
appose the skin and urethral mucosa at the caudal end of the incision end. Close the
cranial end similarly to reduce the risk of subcutaneous urine leakage.
9. Close the remaining subcutis and skin as needed.
10. Pass a urinary catheter through the stoma into the bladder to verify the urethra is
unobstructed.

Postoperative Considerations:

Dogs that have undergone cystotomy should receive intravenous fluids for 12 to 24 hours to
prevent urinary obstruction by blood clots. Sedatives are administered to reduce excitement and
postoperative hemorrhage. A thin layer of petroleum jelly can be placed around the stoma if
urine scald occurs. Dogs should wear Elizabethan collars and be exercise restricted for at least
7 days after the surgery to reduce self trauma and hemorrhage. The stomal sutures are left in
place and usually fall out, or are removed by grooming, within 3 weeks after surgery.

Complications of scrotal urethrostomy include hemorrhage, stricture, urine scald, incisional

infection, dehiscence, and obstruction or cystitis from recurrence of cystic calculi. Hemorrhage
is uncommon when continuous suture patterns are used, unless the mucosa was inadvertently
excluded from the urethrostomy closure. Animals with persistent hemorrhage should be sedated
for one to two weeks. Urine scald may occur if the urethrostomy site is cranial to the scrotum or
too high on the perineum. Stricture is rare as long as the original stoma is sufficient in size and
the mucosa has been accurately apposed to the skin.

Canine Prescrotal Urethotomy

Under general anesthesia, most urethral calculi can be retropulsed into the urinary bladder and
removed with cystoscopy, cystoscopically assisted cystotomy, or open cystotomy. Those that
cannot be shifted are usually lodged within the urethra at the caudal end of the os penis. Many
of these calculi become embedded within the mucosa and are not easily removed, even through
a urethrotomy; in these dogs, scrotal urethrostomy is usually performed. In a few dogs, the
calculus can be dislodged through a prescrotal urethral incision. Prescrotal urethrotomies are
usually closed primarily to reduce postoperative hemorrhage. Urethral incisions that are left
open to heal by second intention will bleed for 3 to 14 days, particularly when animals are
excited. Rarely, dogs may undergo permanent prescrotal urethrostomies. Owners should be
warned of the potential for urine scald along the scrotum and inner thighs.

Feline Perineal Urethrostomy

Permanent enlargement of the urethral opening may be recommended in male cats with
recurrent urinary tract obstruction from calculi or mucoid plugs. Perineal urethrostomy is also
indicated for irresolvable obstruction, strictures, irreparable distal urethral injuries, or neoplasia.
Because perineal urethrostomy (PU) increases the risk for bacterial cystitis in cats with
underlying urinary tract disease, medical management should be attempted before considering
surgery.

Preoperative Management

Cats with urethral obstruction may present with dysuria, stranguria, abdominal pain, and
lethargy. With complete obstruction, they develop uremia, acidosis, hyperphosphatemia,
hyperkalemia, and bradycardia and eventually die. Initial management should focus on relieving
the obstruction and providing intravenous fluids to correct electrolyte abnormalities and
dehydration. Cats may require general anesthesia (e.g. opioids and gas anesthetic) to unplug
the penile urethra. If the obstruction cannot be relieved by catheterization, the bladder should be
completely emptied by cystocentesis. Cystocentesis must be performed carefully, since
overdistended bladders can rupture. Besides routine blood work and urinalysis, plain and
contrast radiographic studies of the bladder and urethra are recommended to rule out etiologies
that can be treated by other means or to determine whether a cystotomy is needed
concurrently. Permanent urethral stenosis is difficult to diagnose on contrast
cystourethrography, since the urethra may swell or spasm after traumatic catheterization.

In preparation for surgery, the perineum and base of the tail are clipped, and a purse string
suture is placed in the anus. An epidural provides excellent postoperative analgesia. The cat
can be positioned in dorsal recumbency with the rear legs pulled forward if a cystotomy is also
needed, or hanging over the end of a tilted surgery table with the tail pulled up and forward. If
cats are placed in the perineal position, the table edge should be padded and the cat’s chest
elevated to reduce pressure on the diaphragm.

Surgery

If the cat is intact, castration can be performed routinely through scrotal incisions or after the
initial periscrotal incision is made. The penile body, which is attached to the pelvis by the ventral
penile ligament and ischiourethralis and ischiocavernosus muscles, must be completely
mobilized to prevent postoperative stricture. Dorsal and lateral dissection cranial to these
muscles should be avoided to reduce the risk of fecal or urinary incontinence secondary to
pelvic nerve damage.

The urethra should be opened to the level of the bulbourethral glands. These glands may be
difficult to visualize during dissection, however, so the ostium diameter can also be tested by
inserting a closed hemostat or 6 or 8 French red rubber catheter, as described below.
Urethrocutaneous apposition is performed with synthetic, rapidly absorbable, 4-0 or 5-0
monofilament suture. Fine tipped needle holders, thumb forceps, and scissors are used when
manipulating urethral tissues. The urethral mucosa, which must be included in each suture bite,
often retracts away from the cut edge of the penile body. Reading glasses (1x) provide excellent
magnification for visualizing the urethral mucosa.

If a cystotomy is performed simultaneously, the bladder can be flushed with a catheter

advanced retrograde through the urethrostomy site. In overweight cats, elliptical pieces of skin
and underlying subcutaneous fat can be removed lateral to the finished urethrostomy to evert
the skin edges.
Surgical Technique: Perineal Urethrostomy
1. Make an elliptical incision around the base of the scrotum and prepuce. Retract the
scrotum and prepuce away from the blade as each side is incised.
2. After incising through the subcutis, use a gauze sponge to strip any remaining fatty
attachments to the penile body. The retractor penis is sometimes removed during this
part of the dissection.
3. Palpate between the penile body and pelvis to identify the ventral penile ligament.
Transect the ligament with Metzenbaum scissors. Gently disrupt any ligamentous
remnants with digital pressure.
4. Retract the penile body laterally to identify the ischiocavernosus and ischiourethralis
muscles. Place a scissor blade on either side of the muscle group and cut the muscle
origins immediately adjacent to the ischium. Palpate ventral to the penile body to verify
that the penis is freely moveable from the caudal half of the pelvic floor.
5. If it is still present, elevate and resect the retractor penis muscle from the dorsal penile
body.
6. Incise the prepuce to expose the penile tip.
7. Insert one blade of the iris scissors into the tip of urethra and cut the urethra along the
dorsal surface of the penile body to the level of the bulbourethral glands. A distinct
crunch can often be felt at the level of these glands when cutting with scissors.
8. Test the diameter of the urethra. The opening should be large enough to accommodate
an 8 Fr red rubber catheter or closed Halsted mosquito hemostats inserted to the level of
the box locks. Extend the incision cranially as needed to widen the opening.
9. Preplace the first 3 sutures from the urethral mucosa to the skin at the 10, 2, and 12
o’clock positions. Take bites of mucosa that are less than 1/3 of the urethral diameter.
10. To place the dorsal most suture, take a bite of skin, then insert a straight Halsted
mosquito hemostat into the urethra. Open the jaws of the hemostat slightly and pass the
needle through the dorsal urethral mucosa. This improves visualization of the dorsal
urethral wall and prevents accidental inclusion of the ventral urethral mucosa.
11. After tying the preplaced sutures, appose the urethral mucosa to the skin on each side
with a simple continuous pattern of rapidly absorbable suture, placing bites 1 to 2 mm
apart. Continue the appositional pattern until the urethra begins to narrow.
 12. Ligate and amputate the distal penile body with absorbable suture before completing the
skin closure. The final drain board is usually 1 to 2 cm long. Remove the anal purse
string when finished.

Postoperative Considerations

Cats should wear an Elizabethan collar for at least 7 days to prevent self-mutilation, which can
increase the risk of strictures. Analgesics are recommended for several days after surgery, and
cats that have undergone simultaneous cystotomy are kept on intravenous fluids for 24 hours.
Absorbable monofilament sutures are left in place and are extruded, covered with epithelium, or
removed by the cat once the Elizabethan collar is removed. Paper litter is often recommended
for the first week after surgery.

Common early complications include hemorrhage and swelling. Hemorrhage is reduced by

using a continuous pattern, including the mucosa in each suture bite, preventing self trauma,
and keeping the cat sedated with acepromazine and opioids immediately after the procedure.
Because the urethral mucosa retracts away from the incision edge, it is easy to miss during
urethrocutaneous apposition. Poor mucosal apposition and postoperative swelling may allow
urine to travel through gaps in the suture line and into the subcutaneous tissues, increasing
postoperative swelling and risk of subsequent stricture. Subcutaneous urine leakage may also
occur with catheter-induced urethral lacerations or suture line inversion secondary to
anastomotic tension (e.g. a short urethra). Urine extravasation often appears as red and yellow
bruising radiating away from the incision site. In cats predisposed to subcutaneous urine
leakage, a 5 Fr Foley catheter can be left in place for 2 to 3 days until the surgical site seals.
Use of catheters is otherwise not routinely recommended because of ascending infection and
urethral irritation.

Other complications include stricture from incomplete dissection, bacterial urinary tract
infections, recurrence of clinical signs, and incontinence. Incontinence is uncommon as long as
dissection is limited, as described above. Clinical signs may reoccur in cats that form calculi or
develop urinary tract infections. Cystitis occurs after perineal urethrostomy in 17 to 40% of cats
with feline lower urinary tract disease; therefore, periodic urinalysis and culture are
recommended. Strictures usually occur within 6 months after surgery and often result from
failure to free the penile body from its pelvic attachments or incise the urethra to the level of the
bulbourethral glands. Strictures are corrected by incising carefully around the urethrostomy and
dissecting the remaining urethra up to the pelvis, where its attachments are transected. The
urethral opening is then widened, tested, and sutured as described above. The resulting drain
board will be much shorter than the original perineal urethrostomy; however, urine scald does
not seem to be a problem in these cats.